criteria Dr. Cristín Ryan Queen s University Belfast [email protected]

Transcription

1 The basics of the STOPP/START criteria Dr. Cristín Ryan Queen s University Belfast [email protected]

2 Overview Why & how STOPP/START was developed Aims of STOPP/START Contents of STOPP/START STOPP/START in prevalence studies Inter rater reliablility of STOPP/START amongst pharmacists STOPP/START in clinical practice

3 The importance of regular medication review in older people + =? Increase in co morbidities with age Physiological changes pharmacokinetics pharmacodynamics Increased susceptibility to: Polypharmacy Drug interactions Adverse drug reactions Prescribing cascade Poor compliance Potentially inappropriate prescribing

4 Potentially inappropriate prescribing defined Risk > Benefit Over prescribing Excessive doses/duration of medicines Polypharmacy Mis prescribing Unfavourable choice of medicine, dose, or duration Under prescribing Not prescribing a clinically indicated medicine, despite the patient not having any contra indication to that medicine

5 Explicit screening tools Screening Tool McLeod (1997) Content Method Prevalence of PIP Globally 38 Indicators Delphi Validation IPET (2000) 14 Indicators Based of McLeod criteria Beers Criteria ( 03) 48 Indicators Delphi Validation 3.0% 31.78% Prevalence of PIP in Ireland 18.3% Primary Care: 10% Secondary Care: 22% Nursing Homes: Primary Care: % Secondary Care: 34% Nursing Home: 40.3% Primary Care: 11 13% Secondary Care:34% Nursing Homes: 56.8% Key: PIP: Potentially Inappropriate Prescribing

6 Need for new criteria Limitations of IPET Limitations of Beers Combined Limitations } STOPP/ START

7 Aims of STOPP/START Provide explicit, evidence based rules of avoidance of commonly encountered instances of potentially inappropriate prescribing and potential prescribing omissions Improve medication appropriateness Prevent adverse drug events Reduce drug costs

8 STOPP/START Consensus panel of 18 experts Delphi process (2 rounds) Final agreed list of STOPP criteria (n=65) and START (n=22) Good inter rater reliability (STOPP k=0.75; START k= 0.68)

9 Contents of STOPP Physiological System Number of criteria Cardiovascular system 17 Central nervous system 13 Gastro intestinal system 5 Musculoskeletal system 8 Respiratory system 3 Urogenital system 6 Endocrine system 4 Drugs that adversely affect fallers 5 Analgesics 3 Duplicate drug classes 1

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15 Contents of START Physiological System Number of criteria Cardiovascular system 8 Respiratory system 3 Central nervous system 2 Gastro intestinal system Musculoskeletal system Endocrine system 4 2 3

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18 Prevalence of Potentially Inappropriate Prescribing using STOPP/START

19 Aims of STOPP/START Provide explicit, evidence based rules of avoidance of commonly encountered instances of potentially inappropriate prescribing and potential prescribing omissions Improve medication appropriateness Prevent adverse drug events Reduce drug costs

20 Medication Appropriateness MAI Score Gallagher et al. Clin Pharm Ther 2011; 89,

21 Gallagher et al. Clin Pharm Ther 2011; 89,

22 Aims of STOPP/START Provide explicit, evidence based rules of avoidance of commonly encountered instances of potentially inappropriate prescribing and potential prescribing omissions Improve medication appropriateness Prevent adverse drug events Reduce drug costs

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24 Aims of STOPP/START Provide explicit, evidence based rules of avoidance of commonly encountered instances of potentially inappropriate prescribing and potential prescribing omissions Improve medication appropriateness Prevent adverse drug events Reduce drug costs

25 Economic implications of potentially inappropriate prescribing Irish population based study using (n=338,801) Potentially inappropriate prescribing rate using 30 STOPP indicators: 36% NIC: % of the overall expenditure on pharmaceutical in those 70 years Cahir C et al. Br J Clin Pharmacol 2010; 69:

26 Inter rater reliability amongst pharmacists when provided with clinical information Ryan C et al. Ann Pharmacother 2009; 43(7):

27 Inter rater reliability amongst pharmacists when provided with clinical information Comparators Median kappa (p< % CI) STOPP APs*HPs 0.89 ( ) APs*CPs 0.88 ( ) Inter HPs 0.82 ( ) Inter CPs 0.78 ( ) START APs*HPs 0.91 ( ) APs*CPs 0.90 ( ) Inter HPs 0.90 ( ) Inter CPs 0.82 ( ) KEY AP: Academic Pharmacists, HP: Hospital Pharmacists, CP: Community Pharmacists Ryan C et al. Ann Pharmacother 2009; 43(7):

28 Inter rater reliability amongst pharmacists without access to clinical information

29 Inter rater reliability amongst pharmacists without access to clinical information Pharmacist K (95% CI, p<0.01) Bisphosphonate in patients taking maintenance corticosteroid therapy CP1 1 CP ( ) CP3 1 PPI for peptic ulcer disease at full therapeutic dosage for > 8 weeks CP ( ) CP ( ) CP ( ) Antiplatelet therapy in diabetes mellitus with coexisting major CV risk factors CP ( ) CP ( ) CP3 1

30 CP ( ) Inter rater reliability amongst pharmacists without access to clinical information Pharmacist K (95% CI, p<0.01) Long-term (i.e. > 1 month), long-acting benzodiazepines with long-acting metabolites CP ( ) CP ( ) CP ( ) PPI for peptic ulcer disease at full therapeutic dosage for > 8 weeks CP ( ) CP ( ) CP ( ) Duplicate Drug Classes CP ( ) CP ( )

31 STOPP/START in practice Growing momentum in the research literature Translated to various European languages Integrated into some geriatric units in secondary care Use as a guide to assist clinical medication review in some primary care and secondary care settings Used as an educational tool for pharmacists and prescribers

32 Future for STOPP/START Limitation: Clinical guideline not to replace expert knowledge In need of regular updating More RCTs: Pharmaco economic model Comparison between screening tool facilitated MUR and full clinical review Long term patient outcomes

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34 Example: 70 Year old male Current Medicines Digoxin 250micrograms od Bendroflumethiazide 2.5mg od Flurazepam 30mg od (past 3 years) Application of STOPP Long term flurazepam

35 Example: 70 Year old male Current Medicines Digoxin 250micrograms od Bendroflumethiazide 2.5mg od Flurazepam 30mg od (past 3 years) Current Diagnoses Hypercholesterolaemia Chronic Atrial Fibrillation Ischaemic Heart Disease Medical History Cataracts, Gout, Insomnia Biochemical Data Chol: 8.8mmol/L egfr 30ml/min/1.73m 2 LFTs within range Application of STOPP Digoxin > 125mcg with impaired renal function Thiazide diuretic and history of gout Long term flurazepam Application of START Warfarin and atrialfibrillation Statin with elevated cholesterol